Ethnic differences and inequities in paediatric healthcare utilisation in the UK: a scoping review

BACKGROUND

Despite the increased policy attention on ethnic health inequities since the COVID-19 pandemic, research on ethnicity and healthcare utilisation in children has largely been overlooked.

OBJECTIVES

This scoping review aimed to describe and appraise the quantitative evidence on ethnic differences (unequal) and inequities (unequal, unfair and disproportionate to healthcare needs) in paediatric healthcare utilisation in the UK 2001-2021.

METHODS

We searched Embase, Medline and grey literature sources and mapped the number of studies that found differences and inequities by ethnic group and healthcare utilisation outcome. We summarised the distribution of studies across various methodological parameters.

RESULTS

The majority of the 61 included studies (n=54, 89%) identified ethnic differences or inequities in paediatric healthcare utilisation, though inequities were examined in fewer than half of studies (n=27, 44%). These studies mostly focused on primary and preventive care, and depending on whether ethnicity data were aggregated or disaggregated, findings were sometimes conflicting. Emergency and outpatient care were understudied, as were health conditions besides mental health and infectious disease. Studies used a range of ethnicity classification systems and lacked the use of theoretical frameworks. Children's ethnicity was often the explanatory factor of interest while parent/caregiver ethnicity was largely overlooked.

DISCUSSION

While the current evidence base can assist policy makers to identify inequities in paediatric healthcare utilisation among certain ethnic groups, we outline recommendations to improve the validity, generalisability and comparability of research to better understand and thereby act on ethnic inequities in paediatric healthcare.

Migrants' primary care utilisation before and during the COVID-19 pandemic in England: An interrupted time series analysis

Background

How international migrants access and use primary care in England is poorly understood. We aimed to compare primary care consultation rates between international migrants and non-migrants in England before and during the COVID-19 pandemic (2015-2020).

Methods

Using data from the Clinical Practice Research Datalink (CPRD) GOLD, we identified migrants using country-of-birth, visa-status or other codes indicating international migration. We linked CPRD to Office for National Statistics deprivation data and ran a controlled interrupted time series (ITS) using negative binomial regression to compare rates before and during the pandemic.

Findings

In 262,644 individuals, pre-pandemic consultation rates per person-year were 4.35 (4.34-4.36) for migrants and 4.60 (4.59-4.60) for non-migrants (RR:0.94 [0.92-0.96]). Between 29 March and 26 December 2020, rates reduced to 3.54 (3.52-3.57) for migrants and 4.2 (4.17-4.23) for non-migrants (RR:0.84 [0.8-0.88]). The first year of the pandemic was associated with a widening of the gap in consultation rates between migrants and non-migrants to 0.89 (95% CI 0.84-0.94) times the ratio before the pandemic. This widening in ratios was greater for children, individuals whose first language was not English, and individuals of White British, White non-British and Black/African/Caribbean/Black British ethnicities. It was also greater in the case of telephone consultations, particularly in London.

Interpretation

Migrants were less likely to use primary care than non-migrants before the pandemic and the first year of the pandemic exacerbated this difference. As GP practices retain remote and hybrid models of service delivery, they must improve services and ensure primary care is accessible and responsive to migrants' healthcare needs.

Funding

This study was funded by the Medical Research Council (MC_PC 19070 and MR/V028375/1) and a Wellcome Clinical Research Career Development Fellowship (206602).

Ethnic Inequalities in Healthcare Use and Care Quality among People with Multiple Long-Term Health Conditions Living in the United Kingdom: A Systematic Review and Narrative Synthesis

Indicative evidence suggests that the prevalence of multiple long-term conditions (i.e., conditions that cannot be cured but can be managed with medication and other treatments) may be higher in people from minoritised ethnic groups when compared to people from the White majority population. Some studies also suggest that there are ethnic inequalities in healthcare use and care quality among people with multiple long-term conditions (MLTCs). The aims of this review are to (1) identify and describe the literature that reports on ethnicity and healthcare use and care quality among people with MLTCs in the UK and (2) examine how healthcare use and/or care quality for people with MLTCs compares across ethnic groups. We registered the protocol on PROSPERO (CRD42020220702). We searched the following databases up to December 2020: ASSIA, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science core collection. Reference lists of key articles were also hand-searched for relevant studies. The outcomes of interest were patterns of healthcare use and care quality among people with MLTCs for at least one minoritised ethnic group, compared to the White majority population in the UK. Two reviewers, L.B. and B.H., screened and extracted data from a random sample of studies (10%). B.H. independently screened and extracted data from the remaining studies. Of the 718 studies identified, 14 were eligible for inclusion. There was evidence indicating ethnic inequalities in disease management and emergency admissions among people with MLTCs in the five studies that counted more than two long-term conditions. Compared to their White counterparts, Black and Asian children and young people had higher rates of emergency admissions. Black and South Asian people were found to have suboptimal disease management compared to other ethnic groups. The findings suggest that for some minoritised ethnic group people with MLTCs there may be inadequate initiatives for managing health conditions and/or a need for enhanced strategies to reduce ethnic inequalities in healthcare. However, the few studies identified focused on a variety of conditions across different domains of healthcare use, and many of these studies used broad ethnic group categories. As such, further research focusing on MLTCs and using expanded ethnic categories in data collection is needed.

Differences in Dementia Care Between Swedish-Born and Foreign-Born from Countries with Different Country Level Socioeconomic Position: A Nationwide Register-Based Study

Background:

With a growing elderly population worldwide, the prevalence of dementia is rapidly increasing. Studies from high income countries have shown that belonging to a minority ethnic group increases the risk of health disadvantages.

Objective:

The aim of the present registry-based study was to identify potential differences in diagnostics, treatment, and care of individuals with dementia focusing on foreign-born in Sweden and the impact of country level socioeconomic position (SEP).

Methods:

The study was based on a large dataset from the Swedish Dementia Registry (SveDem) and the Swedish Tax Agency’s population registry. Data on demographic variables, cognitive tests, clinical assessments, medication, diagnosis, and interventions initiated at diagnosis were collected. Country level SEP was determined by country of birth as classified by World Bank Country and Lending groups.

Results:

Of 57,982 patients with dementia registered in SveDem, 7,171 (12.4%) were foreign-born. The foreign-born were significantly younger at diagnosis (p < 0.001), had a lower MMSE score (p < 0.001), lower odds of receiving a specific dementia diagnosis (p < 0.001), lower use of acetylcholinesterase inhibitors (p < 0.001), and overall a higher use of neuroleptics compared with the Swedish-born group. The lower SEP, the greater differences to Swedish-born were seen in many of the examined variables.

Conclusion:

There were significant differences in dementia diagnostics, treatment, and care between foreign-born and Swedish-born, a lower SEP indicating greater differences. Further research should focus on various socioeconomic aspects and health care outcomes for a more profound analysis of equity in dementia care.

Do ethnic inequalities in multimorbidity reflect ethnic differences in socioeconomic status? The HELIUS study

BACKGROUND

The burden of multimorbidity is likely higher in ethnic minority populations, as most individual diseases are more prevalent in minority groups. However, information is scarce. We examined ethnic inequalities in multimorbidity, and investigated to what extent they reflect differences in socioeconomic status (SES).

METHODS

We included Healthy Life in an Urban Setting study participants of Dutch (N = 4582), South-Asian Surinamese (N = 3258), African Surinamese (N = 4267), Ghanaian (N = 2282), Turkish (N = 3879) and Moroccan (N = 4094) origin (aged 18-70 years). Educational level, employment status, income situation and multimorbidity were defined based on questionnaires. We described the prevalence and examined age-adjusted ethnic inequalities in multimorbidity with logistic regression analyses. To assess the contribution of SES, we added SES indicators to the age-adjusted model.

RESULTS

The prevalence of multimorbidity ranged from 27.1 to 53.4% in men and from 38.5 to 69.6% in women. The prevalence of multimorbidity in most ethnic minority groups was comparable to the prevalence among Dutch participants who were 1-3 decades older. After adjustment for SES, the odds of multimorbidity remained significantly higher in ethnic minority groups. For instance, age-adjusted OR for multimorbidity for the Turkish compared to the Dutch changed from 4.43 (3.84-5.13) to 2.34 (1.99-2.75) in men and from 5.35 (4.69-6.10) to 2.94 (2.54-3.41) in women after simultaneous adjustment for all SES indicators.

CONCLUSIONS

We found a significantly higher prevalence of multimorbidity in ethnic minority men and women compared to Dutch, and results pointed to an earlier onset of multimorbidity in ethnic minority groups. These inequalities in multimorbidity were not fully accounted for by differences in SES.

A narrative synthesis scoping review of life course domains within health service utilisation frameworks

Background: Current thinking in health recognises the influence of early life experiences (health and otherwise) on later life outcomes. The life course approach has been embedded in the work of the World Health Organisation since the Ageing and Health programme was established in 1995. Yet there has been limited debate on the relevancy of a life course lens to understanding health service utilisation. Aim: The aim of the review was twofold. Firstly, identify existing healthcare utilisation frameworks other than the dominant Andersen's behavioural model currently in use. Secondly, to identify if current frameworks incorporate the advocated life course perspective in understanding health service utilisation.     Methods: A scoping review of PubMed, Cinahl Plus, Emerald, PsycINFO, Web of Knowledge and Scopus was conducted. Data extraction used a framework approach with meta-synthesis guided by the four domains of the life course proposed by Elder (1979): human agency, location, temporality and relationships, and interdependencies. Results: A total of 551 papers were identified, with 70 unique frameworks (other than Andersen's Behavioural Model) meeting the inclusion criteria and included in the review. Conclusion: To date there has been limited explicit discussion of health service utilisation from a life course perspective. The current review highlights a range of frameworks that draw on aspects of the life course, but have been used with this perspective in mind. The life course approach highlights important gaps in understanding and assessing health service utilisation (HSU), such as utilisation over time. HSU is a complex phenomenon and applying a structured framework from a life course perspective would be of benefit to researchers, practitioners and policy makers.

The Impact of Being a Migrant from a Non-English-Speaking Country on Healthcare Outcomes in Frail Older Inpatients: an Australian Study

The purpose of this prospective study of 2180 consecutive index admissions to an acute geriatric service was to compare in-hospital outcomes of frail older inpatients born in non-English-speaking counties, referred to as culturally and linguistically diverse (CALD) countries in Australia, with those born in English-speaking countries. Multivariate logistic regression was used to model in-hospital mortality and new nursing home placement. Multivariate Cox proportional hazards regression was used to model length of stay. The mean age of all patients was 83 years and 93% were admitted through the emergency department. In multivariate analyses, patients from CALD and non-CALD backgrounds were equally likely to die (CALD odds ratio [OR] 0.69, 95% confidence interval [95% CI] 0.44-1.10) and be newly placed in a nursing home (OR 0.75, 95% CI 0.51-1.12). Patients from CALD backgrounds unable to speak English were more likely to die (11.5% vs. 7.2%, p = 0.02). While patients from CALD backgrounds had significantly shorter lengths of stay in univariate analysis (median 9 days vs. 10 days, p = 0.02), this was not apparent in multivariate analysis (hazard ratio 1.02, 95% CI 0.91-1.14), where the ability to speak English proved to be a strong confounder. While most of the literature shows poorer outcomes of people from minority ethnic groups, our findings indicate that this is not necessarily the case. Developing culturally appropriate services may mitigate some of the adverse outcomes commonly associated with ethnicity. Our findings are particularly relevant to countries populated by multiple ethnic groups.

Identifying inequitable healthcare in older people: systematic review of current research practice

BACKGROUND

There is growing consensus on the importance of identifying age-related inequities in the receipt of public health and healthcare interventions, but concerns regarding conceptual and methodological rigour in this area of research. Establishing age inequity in receipt requires evidence of a difference that is not an artefact of poor measurement of need or receipt; is not warranted on the grounds of patient preference or clinical safety; and is judged to be unfair.

METHOD

A systematic, thematic literature review was undertaken with the objective of characterising recent research approaches. Studies were eligible if the population was in a country within the Organisation for Economic Co-operation and Development and analyses included an explicit focus on age-related patterns of healthcare receipt including those 60 years or older. A structured extraction template was applied. Extracted material was synthesised in thematic memos. A set of categorical codes were then defined and applied to produce summary counts across key dimensions. This process was iterative to allow reconciliation of discrepancies and ensure reliability.

RESULTS

Forty nine studies met the eligibility criteria. A wide variety of concepts, terms and methodologies were used across these studies. Thirty five studies employed multivariable techniques to produce adjusted receipt-need ratios, though few clearly articulated their rationale, indicating the need for great conceptual clarity. Eighteen studies made reference to patient preference as a relevant consideration, but just one incorporated any kind of adjustment for this factor. Twenty five studies discussed effectiveness among older adults, with fourteen raising the possibility of differential effectiveness, and one differential cost-effectiveness, by age. Just three studies made explicit reference to the ethical nature of healthcare resource allocation by age. While many authors presented suitably cautious conclusions, some appeared to over-stretch their findings concluding that observed differences were 'inequitable'. Limitations include possible biases in the retrieved material due to inconsistent database indexing and a focus on OECD country populations and studies with English titles.

CONCLUSIONS

Caution is needed among clinicians and other evidence-users in accepting claims of healthcare 'ageism' in some published papers. Principles for improved research practice are proposed.

Ethnic differences in colon cancer care in the Netherlands: a nationwide registry-based study

Background

Ethnic differences in colon cancer (CC) care were shown in the United States, but results are not directly applicable to European countries due to fundamental healthcare system differences. This is the first study addressing ethnic differences in treatment and survival for CC in the Netherlands.

Methods

Data of 101,882 patients diagnosed with CC in 1996–2011 were selected from the Netherlands Cancer Registry and linked to databases from Statistics Netherlands. Ethnic differences in lymph node (LN) evaluation, anastomotic leakage and adjuvant chemotherapy were analysed using stepwise logistic regression models. Stepwise Cox regression was used to examine the influence of ethnic differences in adjuvant chemotherapy on 5-year all-cause and colorectal cancer-specific survival.

Results

Adequate LN evaluation was significantly more likely for patients from ‘other Western’ countries than for the Dutch (OR 1.09; 95% CI 1.01–1.16). ‘Other Western’ patients had a significantly higher risk of anastomotic leakage after resection (OR 1.24; 95% CI 1.05–1.47). Patients of Moroccan origin were significantly less likely to receive adjuvant chemotherapy (OR 0.27; 95% CI 0.13–0.59). Ethnic differences were not fully explained by differences in socioeconomic and hospital-related characteristics. The higher 5-year all-cause mortality of Moroccan patients (HR 1.64; 95% CI 1.03–2.61) was statistically explained by differences in adjuvant chemotherapy receipt.

Conclusion

These results suggest the presence of ethnic inequalities in CC care in the Netherlands. We recommend further analysis of the role of comorbidity, communication in patient-provider interaction and patients’ health literacy when looking at ethnic differences in treatment for CC.

Ethnic Inequalities in Rectal Cancer Care in a Universal Access Healthcare System: A Nationwide Register-Based Study

BACKGROUND

Ethnic inequalities in colorectal cancer care were reported previously in the United States. Studies specifically reporting on ethnic inequalities in rectal cancer care are limited.

OBJECTIVE

This study aimed to explore potential ethnic inequalities in rectal cancer care in the Netherlands.

DESIGN

This was a nationwide, population-based observational study.

SETTINGS

The study linked data of the Netherlands Cancer Registry with the Dutch population registry and the Social Statistics Database of Statistics Netherlands. Data were analyzed using stepwise multivariable logistic regression models.

PATIENTS

All of the patients diagnosed with rectal carcinoma in 2003-2011 in the Netherlands (N = 27,159) were included.

MAIN OUTCOME MEASURES

We analyzed 2 rectal cancer treatment indicators (preoperative radiotherapy and sphincter-sparing surgery) and 2 indicators of short-term outcome of rectal cancer surgery (anastomotic leakage and 30-day postoperative mortality).

RESULTS

Patients of Western non-Dutch and non-Western origin with rectal cancer were significantly younger and had a higher tumor stage than ethnic Dutch patients. Considering preoperative radiotherapy, anastomotic leakage, and 30-day postoperative mortality, no ethnic inequalities were detected. After adjustment for age, sex, disease characteristics, and socioeconomic status, Western non-Dutch and non-Western patients were significantly more likely to receive sphincter-sparing surgery than ethnic Dutch patients (OR = 1.27 (95% CI, 1.04-1.55) and OR = 1.57 (95% CI, 1.02-2.42)).

LIMITATIONS

This study was limited by the relatively low numbers of non-Dutch patients with rectal cancer.

CONCLUSIONS

Non-Dutch ethnic origin was associated with a higher rate of sphincter-sparing surgery. The absence of ethnic inequalities in preoperative radiotherapy, anastomotic leakage, and 30-day postoperative mortality suggests that ethnic minority patients have similar chances of optimal rectal cancer care outcomes as Dutch patients.

Focus on migrants with type 2 diabetes mellitus in European Countries

The prevalence of type 2 diabetes mellitus, one of the major causes of morbility and mortality in Europe, is increasing in all European countries. Diabetes is not distributed equally among all population groups, as higher incidence, appearance of complications, and different mortality rates have been observed among migrants and the native population. These differences may be due to genetic profiles, lifestyle, and utilization of the health care system in different ways. Taking into account that the quantity of migrants is nowadays increasing, mainly in the southern part of Europe, the knowledge of diabetes in migrants through a better collection of data is necessary, considering that few limited epidemiological studies have evaluated the importance of this problem in EU countries. A special effort in developing a comprehensive management for native and immigrant populations in order to prevent and cure diabetes should be mandatory. This activity could be helpful to limit the incidence of future diabetes complications and to avoid the consequent burden of the health care system along with a control on its costs. It is clear that diabetes complication prevention is essential for long-term sustainability of the health care system.

Variation in Delivery of Sinus Surgery in the Medicaid Population across Ethnicities

OBJECTIVE

To evaluate differences in sinus surgery rates in the US Medicaid population by ethnicities.

STUDY DESIGN

Retrospective administrative database analysis.

SETTING

US-based outpatient settings.

METHODS

All patients from the MarketScan Medicaid database with endoscopic sinus surgery from 2009 to 2013 were stratified by ethnicity, age (5-year increments, as per US Census), and sex. Crude rates of endoscopic sinus surgery per age group and sex were compiled for all patients and each ethnic group (African American, Caucasian, Hispanics, and others). Age and sex standardization was done with the MarketScan Medicaid overall population as standard. The coefficient of variation, extremal ratio, and chi-square statistics were calculated to determine variation across ethnicities.

RESULTS

Overall sinus surgery rates per 1000 people in the Medicaid population ranged from 0.36 to 0.40 from 2009 to 2013 (African Americans: 0.24-0.26; Hispanics: 0.21-0.37; Caucasians: 0.47-0.56; rate of surgery statistically lower for African American vs Hispanics for 4 of 5 years). The coefficient of variation and extremal ratio ranged from 29.3% to 45.6% and 1.98 to 2.6, respectively. Differences among groups were significant for all years (P < .0001). Comparison of sex-adjusted ratios by age group demonstrated greater rates of surgery in the Caucasian group versus other groups for all age categories.

CONCLUSION

The Medicaid database was selected for this analysis to eliminate payer and wealth as potential confounders in access to health care. Despite this approach, significant differences in surgery rates among ethnic groups were observed. Further research is critical to understand those differences and provide actionable and effective recommendations for change.

Ethnic differences in asthma treatment among Swedish adolescents: A multilevel analysis of individual heterogeneity

AIMS

Adolescents with immigrant or ethnic minority background suffering from asthma receive on average less appropriate anti-asthmatic medication (AAM) than the majority population. However, those findings are based on analyses of differences between group averages which prevents our understanding of individual heterogeneity around the averages. Taking into account individual socioeconomic factors and medical needs, we performed multilevel analysis in order to evaluate if maternal country of birth (MCOB) accurately identifies adolescents with inappropriate AAM use.

METHODS

Using the Swedish Medical Birth Register, we identified all singleton children born between 1988 and 1991 who were residing in the country until they turned 17 and had complete information on the study variables. We applied a two-level multilevel logistic regression analysis with 62 MCOBs at the second and 755,894 children at the first level. Adjusting for socioeconomic and medical factors using a risk score, and including the socioeconomic characteristics of the MCOBs, we obtained both measures of association (odds ratio (OR)) and measures of variance (Intra-class correlation (ICC)).

RESULTS

Comparing with adolescents born from Swedish mothers, all other children had a lower AAM use, especially those whose mothers were from upper-middle- and low-income countries (OR = 0.47, 95% confidence interval: 0.35-0.61). However, the ICC was low (i.e., ICC ≈ 3%) for both preventive and relief AAM.

CONCLUSIONS

MCOB was associated to adolescent use of AAM. However, the small ICC indicates that MCOB is an inaccurate categorization for identifying inappropriate use of AAM among Swedish adolescents.

Does Maternal Country of Birth Matter for Understanding Offspring's Birthweight? A Multilevel Analysis of Individual Heterogeneity in Sweden

Background

Many public health and epidemiological studies have found differences between populations (e.g. maternal countries of birth) in average values of a health indicator (e.g. mean offspring birthweight). However, the approach based solely on population-level averages compromises our understanding of variability in individuals’ health around the averages. If this variability is high, the exclusive study of averages may give misleading information. This idea is relevant when investigating country of birth differences in health.

Methods and Results

To exemplify this concept, we use information from the Swedish Medical Birth Register (2002–2010) and apply multilevel regression analysis of birthweight, with babies (n = 811,329) at the first, mothers (n = 571,876) at the second, and maternal countries of birth (n = 109) at the third level. We disentangle offspring, maternal and maternal country of birth components of the total offspring heterogeneity in birthweight for babies born within the normal timespan (37–42 weeks). We found that of such birthweight variation about 50% was at the baby level, 47% at the maternal level and only 3% at the maternal countries of birth level.

Conclusion

In spite of seemingly large differences in average birthweight among maternal countries of birth (range 3290–3677g), knowledge of the maternal country of birth does not provide accurate information for ascertaining individual offspring birthweight because of the high inter-offspring heterogeneity around country averages. Our study exemplifies the need for a better understanding of individual health diversity for which group averages may provide insufficient and even misleading information. The analytical approach we outline is therefore relevant to investigations of country of birth (and ethnic) differences in health in general.

A state of limbo--in transition between two contexts: Health assessments upon arrival in Sweden as perceived by former Eritrean asylum seekers

BACKGROUND

National statistics have shown that only about 40% of asylum seekers actually attend the optional health assessment offered upon their arrival in Sweden, but the reasons for this have not been fully explored. Health assessments for newly arrived asylum seekers have become a regular practice in most EU countries, but what is performed, how it is organized and whether it is mandatory or not varies between countries.

AIM

The aim of the study was to explore and improve our understanding of how former asylum seekers from Eritrea perceived and experienced the health assessment during their asylum-seeking process.

METHODS

We used a qualitative research approach guided by grounded theory. Semi-structured interviews were conducted with 11 former asylum seekers from Eritrea. Data were analysed based on constant comparative analysis.

FINDINGS

The asylum seekers expressed feelings of ambiguity and mistrust and felt that they were seen only as objects by the Swedish healthcare system during their asylum-seeking process. Poor communication and inability to overcome language and cultural barriers seemed to be the most important findings in the narratives. The core category was defined as 'A state of limbo - in transition between two contexts'.

CONCLUSIONS

There are reasons to believe that these issues with communication negatively affected both the quality of the health assessment and the number of asylum seekers attending the health assessment. Improved communication by the authorities towards the asylum seekers is, therefore, of vital importance.

Differences in health care utilisation between elderly from ethnic minorities and ethnic Dutch elderly

Introduction

In the Netherlands, as in other Western countries, ethnic minority elderly are more often in poorer health than the indigenous population. The expectation is that this health disadvantage results in more frequent use of health care services.

Methods

We studied registered data on the proportion of health care receivers, frequency of use, and health care costs collected by a major Dutch health insurance company in 2010. Data from 10,316 Turkish, 14,490 Moroccan, 8,619 Surinamese, and 1,064 Moluccan adults aged 55 years and older were compared with data from a sample of 33,725 ethnic Dutch older adults.

Results

Unadjusted and adjusted (for age and gender) analyses showed the following. Moluccans had lower usage levels for all types of health care services. Use of primary health care facilities was higher for Turks, Moroccans, and Surinamese compared with the ethnic Dutch, with the exception that physical therapy was less frequently used among the Turks and Moroccans. Use of hospital care was lower, except for the Surinamese, who had a similar level of usage to that of the ethnic Dutch.

Conclusions

The health disadvantage previously observed within most ethnic minority elderly populations does not result in an overall more frequent use of health care services. Further research is needed for the interpretation of the ethnic variations in health care use as potentially inequitable, by taking medical need, patient treatment preferences, and treatment adherence into account.

Healthcare consumption by ethnic minority people in their country of origin

BACKGROUND

Studies from the USA, New Zealand and Denmark suggest that many ethnic minority citizens obtain healthcare in their country of origin. Their reasons for doing so and the possible consequences remain unclear.

METHODS

We used data from the Healthy Life in an Urban Setting study to investigate the magnitude, types, self-reported reasons and determinants of past-year healthcare consumption in the country of origin by ethnic minority people living in the Netherlands. Individuals of African Surinamese (n = 2059), South-Asian Surinamese (n = 1915), Ghanaian (n = 1426), Moroccan (n = 1516) and Turkish (n = 2245) origin were included (recruited 2011-2013). We performed descriptive and stepwise logistic regression analyses.

RESULTS

Respondents of Turkish origin reported the highest healthcare utilization in the country of origin (21.3%) compared with Moroccan (9.8%), Ghanaian (6.6%), African Surinamese (4.8%) and South-Asian Surinamese (3.0%) respondents. The main services used were outpatient clinics, pharmacies and health centres. The chief reported motivations were healthcare for illness, dissatisfaction with care in the residence country and seeking second opinions. Physical health status, cultural distance to the Dutch healthcare system and Turkish origin were all independently associated with healthcare use in countries of origin.

CONCLUSION

Both health status and attitudes towards services in the countries of residence and origin are significantly associated with cross-border healthcare use. Further research is needed to clarify the reasons for the relatively high rates shown by Turkish respondents and to explore the consequences for health and for healthcare utilization in the country of residence.

Under-treatment of migrants with diabetes in a universalistic health care system: the ARNO Observatory

AIMS

To assess whereas prevalence, treatment and direct costs of drug-treated diabetes were similar in migrants and in people of Italian citizenship under the universalistic Italian health care system.

METHODS AND RESULTS

Drug-treated diabetic individuals were identified in the population-based multiregional ARNO Observatory on the basis of 2010 prescriptions. Migrants were identified by the country-of-birth code on the fiscal identification code. Diabetes prevalence was calculated for Italians (n = 7,328,383) and migrants (n = 527,965). To assess the odds of migrants of having diabetes compared to Italians, we individually matched all migrants to Italians for major confounders (age, sex and place of residence). Finally, all migrants with diabetes were individually matched for confounders to Italians with diabetes to compare prescriptions, hospitalization rates, services use and direct costs for the National Health System. We identified 368,797 subjects with diabetes among Italians and 10,336 among migrants, giving prevalence of 5.03% and 1.96%, respectively. Migrants with diabetes were younger than Italians (52 ± 13 years vs. 68 ± 14 years, P < 0.001); after matching, their risk of disease was higher (odds ratio, 1.55, 95% confidence interval, 1.50-1.60). The total cost was 27% lower in migrants, due to lower cost of drugs (-29%), hospital admission (-27%) and health services (-22%). The number of packages/treated person-year of all glucose-lowering drugs was also lower in migrants (-15%) (P < 0.001).

CONCLUSIONS

Compared to subjects of Italian ancestry, migrants to Italy show a higher risk of diabetes but less intense treatment. Inequalities in health care use are likely and are maintained also in a universalistic system.

Ethnic variations in unplanned readmissions and excess length of hospital stay: a nationwide record-linked cohort study

Background: Studies in the USA have shown ethnic inequalities in quality of hospital care, but in Europe, this has never been analysed. We explored variations in indicators of quality of hospital care by ethnicity in the Netherlands. Methods: We analysed unplanned readmissions and excess length of stay (LOS) across ethnic groups in a large population of hospitalized patients over an 11-year period by linking information from the national hospital discharge register, the Dutch population register and socio-economic data. Data were analysed with stepwise logistic regression. Results: Ethnic differences were most pronounced in older patients: all non-Western ethnic groups > 45 years had an increased risk for excess LOS compared with ethnic Dutch patients, with odds ratios (ORs) (adjusted for case mix) varying from 1.05 [95% confidence intervals (95% CI) 1.02–1.08] for other non-Western patients to 1.14 (95% CI 1.07–1.22) for Moroccan patients. The risk for unplanned readmission in patients >45 years was increased for Turkish (OR 1.24, 95% CI 1.18–1.30) and Surinamese patients (OR 1.11, 95% CI 1.07–1.16). These differences were explained partially, although not substantially, by differences in socio-economic status. Conclusion: We found significant ethnic variations in unplanned readmissions and excess LOS. These differences may be interpretable as shortcomings in the quality of hospital care delivered to ethnic minority patients, but exclusion of alternative explanations (such as differences in patient- and community-level factors, which are outside hospitals’ control) requires further research. To quantify potential ethnic inequities in hospital care in Europe, we need empirical prospective cohort studies with solid quality outcomes such as adverse event rates.